SCVS - Carotid Artery Stenting May Be Performed Safely in Patients with Radiation Therapy Associated Carotid Stenosis Without Increased Restenosis or Target Lesion Revascularization: Results of a Multi-center Review

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Carotid Artery Stenting May Be Performed Safely in Patients with Radiation Therapy Associated Carotid Stenosis Without Increased Restenosis or Target Lesion Revascularization: Results of a Multi-center Review
Reid A. Ravin, MD^¹, Armand Gottlieb, B.S.^¹, Kyle Pasternac, B.S.^¹, William Beckerman, MD^¹, Daniel Fremed, MD^¹, Rami Tadros, MD^¹, Neal Cayne, MD^², Darren Schneider, MD^³, Prakash Krishnan, MD^¹, Michael Marin, MD^¹, Peter L. Faries, MD^¹.
^¹Mount Sinai School of Medicine, New York, NY, USA, ^²New York University School of Medicine, New York, NY, USA, ^³Weill Cornell School of Medicine, New York, NY, USA.

OBJECTIVE
Neck radiation therapy (XRT), may induce carotid artery atherosclerosis, and may increase the technical difficulty of endarterectomy(CEA). It is considered a relative indication for carotid angioplasty and stenting (CAS). This study sought to evaluate differences in CAS embolic potential and restenosis performed on XRT and non-XRT patients.
METHODS
Three hundred and sixty-six CAS procedures were performed on 321 patients (XRT [N = 43], non-XRT [N = 323]) at three institutions. Mean follow-up was 410 days (median, 282 days; range, 3-1920 days). Patients were followed with duplex ultrasound to assess for restenosis. Additional endpoints included target lesion revascularization, myocardial and cerebrovascular events and perioperative complications. Captured particulate from embolic protection filters were analyzed using photomicroscopy and image analysis software for 27 XRT and 214 non-XRT filters.
RESULTS
XRT patient were more likely to be male, and had lower rates of HTN, CAD and DM, although the mean age at procedure did not differ (Table). There was a trend towards increased severe internal carotid tortuosity among XRT patients (XRT: 50% vs. non-XRT: 34.7% P=.05). Indication for CAS did not differ between the two groups, including the number of CAS performed for symptomatic carotid stenosis (XRT: 39.7% vs. non-XRT: 39.0% P=NS). Perioperative outcomes, including the composite 30 day stroke/myocardial infarction/mortality were not significantly different (XRT: 2.6% vs. non-XRT: 3.9% P=NS.) There was no significant differences in restenosis rate at the 50% (XRT: 9.4% vs. non-XRT: 8.6% P=NS) or 70% (XRT: 3.5% vs. non-XRT: 8.6% P=NS) threshold. Filter particle analysis revealed that filters from XRT patients had more numerous large particles per filter and larger particles (Table). Target lesion revascularization(TLR) did not differ significantly between the groups.
CONCLUSIONS
In contrast to earlier studies, this analysis reveals that there are significant differences in XRT and non-XRT patients undergoing CAS, in terms of medical comorbidities, anatomy and embolic potential. Decreased incidence of atherosclerotic risk factors was observed in XRT patients likely because XRT was the primary factor responsible for carotid stenosis. Despite increased tortuosity and embolic particle size, CAS can be performed safely with no increased morbidity, TLR or restenosis in XRT patients.
Table 1. Demographics and Particulate Data (P values by chi-square and T-test)
XRT Non-XRT P value
Mean Age 68.9 71.1 NS
Male 79% (n=34) 56.7% (n=183) P<.01
HTN 63.4% (n=26) 90.6% (n=292) P<.0001
CAD 36.5% (n=15) 59.6% (n=192) P<.05
DM 19.5% (n=8) 36.3% (n=117) P <.05
Particulate Data
Mean maximum particle size / filter(μm) 1.4 .74 P<.05
Mean maximum particle size / filter(μm) 1504.5 307.8 P<.01

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